Global public health has recently been the focus of increasing attention from the interdisciplinary worlds of policy and politics, academia, private foundations, civil society, the media and the general public. This is likely the result of the convergence of a number of seemingly disparate features of the current public health landscape and is not surprising given recent current events – the earthquake in Haiti, healthcare reform in the United States, and aging populations all over the world experiencing rising rates of chronic diseases, such as cancer and diabetes [1]. This article will explore some of the most salient recent trends in global health and its affiliated fields to understand in what direction the discipline is moving and offer some modest recommendations as to how the field may adapt to an increasingly globalized world. This article will focus on education and training, human rights, technology, civil society, new money and public-private partnerships (PPPs) to give the reader, who may not be familiar with the broad scope of this field of study, an overview of some recent developments in global public health and their consequences for practitioners.

The spread of HIV/AIDS, SARS, H1N1 and various non-communicable diseases has confirmed that “diseases do not need visas”. The field of global health has emerged as a significant public health focus, though a clear definition of the discipline remains under debate. Indeed, visionaries such as Julio Frenk see them as one and the same [2], while others, for example the Consortium of Universities of Public Health have a more complex view in which global health is simultaneously a notion, an objective, and/or “a mix of scholarship, research, and practice” [3]. The definition the group ultimately presented read “global health is an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.” Despite the burgeoning popularity of global health, however one may define it, training and educational opportunities remain relatively scarce. In the United States, for example, only about 20 universities (out of hundreds) offer a graduate degree program in global health – formerly known as “tropical” or “international” health – and programs at undergraduate institutions are few and far between [4]. There are even fewer programs for global health study in developing countries [5] where the need is arguably greatest. The noticeable recent surges of academic enthusiasm for the field of global health have not been sufficiently matched by significant increases in training opportunities, especially for younger students [6].

A second concept that has emerged to change the face of global health is that of health as a human right. Often still understood from within its conceptual framework or as solely a process for transformation, [7] health as a human right has actually become quite mainstream and certainly is increasingly operationalized by a variety of private foundations, bi- and multilateral organizations and governments. Many countries have even incorporated the right to health into their constitution. Development of the rights-based approach came about in reaction to pervasive stigma and discrimination around the early stages of the HIV/AIDS epidemic and has since diffused to many areas of public health, especially within low resource settings. Whether the rights-based approach is used explicitly or implicitly, it is clear that it is more frequently being applied to programming, rules and regulations along with the right to education, employment and development [8]. This focus may have decreased disparities within countries, but strangely enough has the potential to increase certain disparities between countries as some adopt these principles and others do not. It is thus the role of public health practitioners, policy-makers and government officials, to use a human rights framework in his or her approach and to encourage others to do so as well. Only then will this field become fully integrated.
A third and quite transformational evolution in the field of global health has been the development of new technologies, as well as the new use of old technologies in innovative ways. For example, the challenges presented by the disaster in Haiti and the associated public health issues such as water, sanitation and the spread of disease, gave rise to alternative ways to manage crises. Cell phones were especially useful for mapping damage, coordinating relief efforts, reuniting families, donating money and for helping ordinary people find their voices amidst the rubble [9]. Media attention in the form of live feeds and real-time interviews certainly contributed to the world’s understanding of the crisis and their subsequent outpouring of financial, technical and religious support. Apart from the crisis, service provision and data collection is slowly but surely being revolutionized by the use of cell phones to administer checklists and provide real-time training and support [10]. The idea is that better quality data, monitoring and evaluation will yield more effective uses of resources and more successful future programming.

A fourth development has been the rise of civil society, especially international non-governmental organizations (NGOs) or civil society organizations (CSO). Their increasing prominence, connectedness, and centrality to global health priority-setting cannot be understated [11]. The NGO community has successfully lobbied, instructed and altered the work of multilateral, bilateral and government agencies and is global in scope and influence. For example, successful lobbying on drug access and pricing and tobacco advertising has proven “transnationally” transformative in the support of the public interest [12]. Spurred themselves by new technologies [13], civil society organizations (CSOs) are able to occupy the unique position of both “watchdogs as well as collaborators” [14]. NGOs may have, however, muddied the waters of global efforts towards accountability, though new NGOs have sprung up to monitor the old [15].

Lastly, the increasing popularity of alternative ways and means to improve global health has generated the need and opportunity for creative new partnerships. For example, private foundations such as the Bill and Melinda Gates Foundation have provided enormous financial support for both mainstream and neglected global health issues from sexual health programs for urban sex workers in India to striving to eliminate onchocerciasis (river blindness) in Colombia [16]. Additionally, public-private partnerships (PPPs) are more often being used to leverage private sector efficiency to solve public sector problems [17]. Both have undoubtedly contributed significantly to the often scattered and uncoordinated field of global health with new reincarnations of functional organizational behavior, technological and human resources development, and program management. The realization of the importance of working with both the public and the private sector is essential to global health practitioners’ effectiveness. The fields of business, international relations and finance have certainly contributed to significant advances in global health and we must learn as much possible from this interdisciplinary collaboration.

In light of the developments discussed above, representing only a select few that I find most illustrative, the evidence that the face of global health has been and still continues to evolve is quite convincing. With such growth and development come both significant challenges and opportunities for both practitioners and the public. We tend to point our fingers, in the event of program failure or frustration, at a lack of resources or of political will. But I point mine – in the spirit of constructive criticism – at the scattered understanding and capacity of this emerging field. The palpable lack of accord in priority-setting and the dearth of training opportunities for interested young people have handicapped our ability to tackle the real public health issues. The current relative lack of consensus and preparedness in the wake of expanding interest in and commitment to global health is concerning. It seems, therefore, critically important to cultivate academic, civil society and political enthusiasm for the topic in order to assure that future generations have the focus, capacity, and knowledge necessary to set priorities and work together.

The field of global health is currently almost exclusively pursued at higher institutes of learning in the developed world, to its detriment. With decreasing life expectancy in Sub-Saharan Africa, an obesity epidemic in the United States, and indigenous populations all over the world suffering significantly poorer health than their non-indigenous counterparts, public health should be one of the most active areas of work and study in our world today. However, both low- and high-income settings lack the training opportunities needed in emerging public health fields. Spatial and geographic methods, low-resource-appropriate health technology, complex data management, monitoring and evaluation, demographics of aging, methods for accountability and a better understanding of health economics, systems and policy are just a few of these neglected sub-fields. The challenge is therefore to translate new and welcome enthusiasm into the skills and capacity to enable young people to contribute to the field in a both a constructive and a cooperative manner.

Most importantly, the field of global health should, indeed, be global [18]. It should certainly not be simply a discipline intended to increase a university’s prestige, attract funding, or ever perpetuate the image of professionals from low-income settings as not working in “global health” [19]. It is therefore necessary to increase training opportunities in the low-resource-settings themselves – not for international students, but for locals – and to improve programs already in existence so that they may meet growing needs and interests. New and creative approaches are needed, however, as currently employed programs and incentives do not seem always to attain their desired results [20]. For example, Dr. Lincoln Chen and colleagues in 2004 proposed a health systems approach to improve workforce capacity in low-income settings using a multidisciplinary local approach benefiting from “appropriate international reinforcement” i.e. supplemental funding [21]. Their suggestion to mobilize a collaborative strategic plan can certainly be applied to other aspects of training in global health whether it be integrating human rights into government policy, collaborating effectively with civil society, human resources strengthening by task shifting, or improving efficiency through new partnerships and technologies. The framework’s call for “immediate action backed by simultaneous learning” certainly applies to the need for improved training and capacity building in all areas of the discipline.

The birth of global health and its growing pains can be seen as both an opportunity and a challenge in our globalized world of scarce resources. The changes in the discipline described above can be seen as wonderful developments to be taken advantage of. It is important in discussions of global public health not to bemoan our lack of resources or lack of political will as barriers to achieving our goals. More important is the need for pertinent training [22] and an ability to integrate solutions and work together, whether it be to combat the emergence of a highly infectious disease or disseminate a new checklist to improve patient care. All worthwhile initiatives lack funding, but the difference between those that achieve something and those that do not is the way in which they use the limited resources they have. Nowadays, the field of global health can boast enormous enthusiasm, media coverage, technological partnerships and advancement, human rights street cred, sophisticated techniques for data collection and analysis, and reach far across sectors from business to anthropology. We therefore must stop bemoaning what we don’t have and cultivate what we do.

Laura Nolan Khan
Department of Global Health and Population,
Harvard School of Public Health
LKHAN(a)hsph.edu

References

1. Economist Intelligence Unit. Breakaway: The global burden of cancer— challenges and opportunities. 2009. Available from: http://livestrongblog.org/GlobalEconomicImpact.pdf
2. Fried LP, Bently ME, Buekens P, Burke DS, Frenk JJ, Klag MJ, Spencer HC. Global Health is Public Health. Lancet. 2010;375(9714):535-537.
3. Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, Wasserheit JN et al. Towards a common definition of global health. Lancet. 2009. 373(9679):1993-1995.
4. Association of Schools of Public Health. Accessed March 22, 2010 http://www.asph.org/document.cfm?page=1107
5. Gewin V. The global challenge. Nature. 2007;447(17):348-349
6. Riegelmen RK & Albertine S. Recommendations for Undergraduate Public Health Education. 2008. Association of American Colleges of and Universities & Association for Prevention Teaching and Research.
7. Gruskin S, Mills EJ, Tarantola D. History, principles and practice of health and human rights. Lancet. 2007;370(9585):449-55.
8. Tarantola D, Byrnes A, Johnson M, Kemp L, Zwi A and Gruskin S. 2008. Human Rights, Health and Development. Technical Series Paper #08.1. Sydney: The UNSW Initiative for Health and Human Rights, The University of New South Wales.
9. Giridharadas A. Africa’s Gift to Silicon Valley: How to Track a Crisis. Accessed March 22, 2010 http://www.nytimes.com/2010/03/14/weekinreview/14giridharadas.html?ref=todayspaper
10. D-Tree International. D tree approach. Accessed April 6, 2010 http://www.d-tree.org/index.php?pid=7
11. Matthews JT. Power Shift. Foreign Affairs. 1997;76(1):50-66.
12. WHO. Strategic Alliances: The role of civil society in health. Discussion Paper No. 1. December 2001.
13. Reich MR. Reshaping the state from above, from within, from below: implications for public health. Social Science & Medicine. 2002;54:1669–1675.
14. Shaw RP. The Interface between CSOs and the World Bank; An Input to Global Health or Global Harm? 2007. Workshop on “Civil Society Organizations and Global Health” Wall Summer Institute for Research, June 25-28. The Peter Wall Institute for Advanced Study. University of British Columbia Vancouver, Canada.
15. Christensen J. Asking the Do-Gooders to Prove They Do Good. New York Times. January 3, 2004 B9: 1
16. Bill & Melinda Gates Foundation. Progress Against Neglected Tropical Diseases. 2009.
17. Reich MP. Public-Private Partnerships for Public Health. 2000. Nature Medicine. 6(6): 617-20.
18. Merson MH & Shaw KC. The Dramatic Expansion of University Engagement in Global Health. Implications for US Policy. 2009. Center for Strategic & International Studies. Washington, DC.
19. Macfarlane SB, Jacobs M, Kaaya EE. In the name of global health: Trends in academic
institutions. Journal of Public Health Policy. 2008;29(4):383–401.
20. Bärnighausen T & Bloom DE. Changing Research Perspectives on the Global Health Workforce. 2009. NBER Working Paper 15168.
21. Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M. Human resources for health: overcoming the crisis. Lancet. 2004;364:1984–90.
22. Keiger D. The Buck Goes Here. 2010. Johns Hopkins Magazine. Baltimore, MD.

Heads of state at the Millenium Summit. Image Credit: www.kremlin.ru.

In today’s blog, Maddy Gimzewska discusses the significance and symbolism of international summits and conferences, and what they represent in terms of international cooperation on global issues.

Conferences remain important due to high coverage and their symbolism of global unity

The globalisation of international politics is a phenomenon which has transformed the way our political systems work. By living in an interdependent world, issues are no longer limited to individual countries. Likewise, medical students and doctors are practising in a more internationally aware profession, which is engaging in health issues at a global level. One of the ways in which international problems are addressed is through global summits addressing specific issues, many of which target health. Yet in the aftermath of the Climate Change Conference in Copenhagen, questions arise regarding the feasibility of global cooperation on important issues. Following two weeks of discussion all that emerged was a weak agreement, which may prove inadequate in stabilising climate change, and lacking legal authority. So what does this symbolise in terms of current international cooperation? Is it realistic for global agreements to be reached, or is the scale of problems facing the international community too great an obstacle to overcome in negotiations?

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Skulls of some of the victims of the Khmer Rouge regime are now kept in a commemorative Buddhist ‘stupa’ at the Killing Fields of Choeung Ek, Phnom Penh.

Introduction

Cambodia, a developing, post-conflict country, underwent cruel and dramatic reorganisation by the Khmer Rouge (KR) between 1975 and 1979 in attempt to convert the country into a Maoist peasant-dominated agrarian society. Although the issue of how many died in this traumatic conflict remains controversial, there has been an estimated 1.5 to 3 million deaths (20-40% of the Cambodian population) [1, 2] and millions others exposed to slave labour under harsh conditions [3]. These atrocities committed by the KR are documented as ‘genocide’ [3]. Amongst the crimes committed were massive killings and starvation, large-scale population transfers, forced labour on collective farms and a near destruction of the school system. One of the interesting theories which sparked the start of the regime was the secret bombing campaign in the final stages of the US-Vietnam war. This plan was masterminded by former US Secretary of State Henry Kissinger and former US president Richard Nixon, involving 240 000 tons of bombs being dropped in Cambodia, which was 50% more than the Allies dropped on Japan [4]. The KR used this as propaganda for their radical policies.

Photos of the victims of the genocide at Tuol Sleng. Most were buried in unmarked graves.

Many studies have reported post-traumatic stress disorder (PTSD), somatic symptoms and disability amongst the survivors of this ordeal, but such results were based on samples drawn from specific groups such as refugee camps [5, 6]. Although the effects of PTSD as a whole in the Cambodian population still remains somewhat ambiguous, the evidence of the emotional impact of the KR regime has been identified and documented.

There has been an immense impact of this ‘genocide’ on the Cambodian people. In reality, this should be compared to the likes of the infamous killings in Rwanda and Yugoslavia. This article is a factual account of the epidemic of psychiatric health problems and the long and troubled wait for justice and mental healthcare by the Cambodians after the KR.

Sequence of Traumatic Events

After the Vietnamese invasion in December 1978 which caused the downfall of KR, millions fled to the Thai-Cambodian border [6]. In 1982, over 350 000 Cambodians were officially classified as displaced persons, and were receiving assistance from eight camps under the United Nations Border Relief Operation [7]. In a study conducted by Mollica et al, more than 83% of all victims reported experiencing a lack of food and water, and forced labour, ill health without medical care, brainwashing, lack of shelter, and forced separation from family under the KR regime [5]. More than half experienced the murder of a family member or close friend, being close to death themselves, isolation from others, and forced evacuation from their homes [5]. Smaller but significant numbers reported torture (35.8%), rape or sexual abuse (17.0%), serious injury (17.8%), beatings to the head or other parts of the body (17.8-26.0%), near drowning (26.7%), loss of consciousness (15.1%), and near suffocation (13.1%) [5]. From 1980-1990, these brutal acts were transformed to various problems experienced while living in a refugee camp, such as inadequate food, water and shelter, bombing and shelling, armed robbery, and domestic violence [5].

Children held captive at the Tuol Sleng prison were beaten against this tree. There were other trees in the compound which had loudspeakers playing music to drown out cries of the victims during the regime.

Mental Health Issues after KR

Unlike many countries worldwide, Cambodia was not challenged by a deinstitutionalisation of their mental health facilities, but the inadequate redevelopment of formal mental health infrastructures [8]. During the KR rule, the killings of the two remaining psychiatrists in the whole country left Cambodia without any psychiatric care, which led to dependency on alternative therapy for spiritual healing [9]. To make matters worse, many were left with the unfortunate legacy of psychological as well as somatic symptoms for many years after the KR (Figure 1). Some survivors could not decide if life was worth living, resulting in 5.6% attempting suicide while living in the refugee camp [5].

Figure 1: Self-reported health problems amongst Cambodians in the Thai-Cambodian Border Camps [5]

Of the 13 symptoms described by Mollica et al [5], the highest reported symptom was ‘bebotchit’, a deep sadness within oneself, caused by unfortunate events which lies so deeply within a person that it can go unnoticed by others. Additional depressive symptoms experienced by this same group were srongot srangat, a visible sadness far worse that bebotchit, hopelessness, worthlessness, and suicidal tendencies. Recent studies on Cambodian immigrants in the US based on the Hopkins Symptom Checklist-25, which measures symptoms of anxiety and depression, showed that 55.0% scored with major depression based on the DSM-III-R criteria [10]. In addition, many Cambodians with depression presented with somatic symptoms, such as frequent headaches, weakness, dizziness, poor appetite, and cold hands or feet [5], and some already had existing psychological symptoms of depression. Of these somatic symptoms, headaches and dizziness were the commonest. They are believed to be a cultural expression of emotional distress and are associated with chief complaints of psychiatric illness in Cambodian adults [11]. Furthermore, the Harvard Trauma Questionnaire for Cambodians living in the US found that the prevalence of many of these individual symptoms may constitute the Western diagnosis of PTSD [12].

With an aim to improve and redevelop the mental health services in Cambodia, a Mental Health Subcommittee (MHSC), which is an extension of the Ministry of Health (MoH) Coordinating Committee assisted by the World Health Organisation (WHO), was formed. The MHSC, chaired by an influential Khmer psychiatrist, include other Khmer psychiatrists, WHO officials, and western expatriates from international non-governmental organisations (NGOs). Although the MHSC has contributed to mental health services, its resources remain limited because they relied heavily on external funds from NGOs and the MoH failed to allocate adequate finances [13]. Regardless of these complex factors, in 2002, human resources have identified 350 mental health-care providers: 20 psychiatrists, 20 psychiatric nurses, and 215 psychiatric clinical psychologists. This achievement offers some degree of primary and acute mental health care facilities, both public and private, with assistance primarily from NGOs [8]. Unfortunately, there are no professionally-trained psychiatric social workers or occupational therapists [8].

Getting Away with Genocide

Amongst the many instruments used by the Khmer Rouge to torture and interrogate prisoners at the notorious Tuol Sleng Security Prison (S-21).

Cambodia is a complex case study of double standards and selectivity of international humanitarian law [14]. After a series of long drawn-out negotiations from 1979 to 2003, a special tribunal, sponsored jointly by the United Nations and the Kingdom of Cambodia (‘Extraordinary Chambers in the Courts of Cambodia’ or ‘Khmer Rouge Trials’) was finally empanelled in order to try the senior leadership of the KR [14]. In the last three years, 5 top leaders have been arrested for pre-trial hearings [15]. On the other hand, Pol Pot, who was guilty of some of the worst crimes in the twentieth century, cheated justice with his death in 1998. In contrast to the Yugoslavian and Rwandan conflicts, the initiations for these trials have taken a longer time. Some have speculated that the delay was due to previous support of the KR by other governments, including China, Singapore, Thailand, the US and the UK [14]. This initial hesitance was due to concerns about rebuilding a shattered nation [14].

Finally, it is important to consider the effects of the tribunal on the Cambodian people as they are directly involved in these trials. The stated primary goals of the trials are to assess the guilt or innocence of the accused in order to decide on suitable punishment for the guilty. By holding these tribunals, both anger and desire for revenge which are associated with the prevalence and severity of PTSD in Cambodians may be reduced [16]. Some have suggested that bringing the guilty to justice may indirectly lessen feelings of vengeance in a country of previous widespread violence [17]. In contrast, others have suggested that the trials may provoke an increase in the prevalence and severity of PTSD by ‘retraumatizing’ the survivors [18].

Conclusion

Regardless of whether PTSD is dealt with by mental health care providers or in a form of a tribunal bringing criminals to justice, it is not clear that psychological scars left on Cambodians by the genocide will heal anytime soon. Some analysts have reported that none of the top communists will ever be put on trial due to fear of shaking the political stability the country is struggling to achieve [14]. Others, such as the former executive director of the Khmer Institute of Democracy, have criticised that the government is ‘buying time’ until all the top leaders die [14]. This event raises important questions for the advocates of human rights: Why did the world wait for a quarter of a century before these criminals stood in court? Why should Cambodia be deprived of international humanitarian law which should be applied justly to every country in the world? Furthermore, these trials are arguably lacking in legitimacy because of the narrow focus on KR officials during the period of the genocide, while ignoring the role of officials from other countries who also committed crimes against humanity in Cambodia, such as Henry Kissinger.

Despite the pressures and obstacles faced now, there is a hope amongst many. By raising awareness of this genocide which left millions dead and even more with chronic mental health issues, the Cambodian people cannot be cheated again and all the living KR co-conspirators will ultimately face up to justice.

Christine Chew is a 4th year medical student at the University of Manchester
christine.chew(at)student.manchester.ac.uk

References:

1. Kiljunen K. Power politics and the tragedy of Kampuchea during the seventies. Bull Concerned Asian Scholars. 1985: 1749-1764.
2. Hannum H. International law and Cambodian genocide: the sounds of silence. Hum Rights Q. 1980; 11: 82-138.
3. Kiernan B. The Pol Pot Regime: race, power and genocide in Cambodia under the Khmer Rouge, 1975-79. 2nd ed. New Haven and London: Yale University Press; 2002.
4. Shawcross, W. Sideshow, Revised Edition: Kissinger, Nixon and the destruction of Cambodia. London, England: Hogarth; 1986.
5. Mollica R, Donelan K, Tor S, et al. The effect of trauma and confinement on functional health and mental status of Cambodians living in the Thai-Cambodia border camps. JAMA. 1993; 270: 581-586.
6. Glass RI, Cates W Jr, Neiburg P, et al. Rapid assessment of health status and preventative- medicine needs of the newly arrived Kampuchean refugees, Sa Kaeo, Thailand. Lancet. 1990; 1: 868-872.
7. United Nations Security Council. Report of the Secretary General on Cambodia. New York, NY: United Nations Security Council; February 19, 1992.
8. Stockwell A, Whiteford H, Townsend C, Stewart D. Mental health policy development: case study of Cambodia. Australasian Psychiatry. 2005; 13: 190-194.
9. Mental Health Subcommittee Working Group. Draft Cambodian National Mental Health Plan 2003-2022. Phnom Penh: Ministry of Health, 2002.
10. Mollica R, Wyshak D, de Marneffe D, et al. Indochinese versions of Hopkins Symptoms Checklist-25: a screening instrument for the psychiatric care of refugees. Am J Psychiatry. 1987; 144: 497-500.
11. Mollica R, Wyshak D, Lavelle J. The psychosocial impact of war, trauma and torture on Southeast Asian refugees. Am J Psychiatry. 1987; 144: 1567-1572.
12. Mollica R, Caspi-Yavin Y, Bollini P, et al. The Harvard Trauma Questionnaire: validating a cross-cultural instrument for measuring torture, trauma and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis. 1992; 180: 111-116.
13. Hu T. Financing global mental health services and the role of WHO. The Journal of Mental Health Policy and Economics. 2003; 6: 145-147.
14. Fawthrop T, Jarvis H. Getting away with Genocide? Cambodia’s long struggle against the Khmer Rouge. London, England: Pluto Press; 2004.
15. Extraordinary Chambers in the Courts of Cambodia. Phnom Penh, Cambodia: ECCC. [Accessed on: February 12, 2010]. Available from: http://www.eccc.gov.kh/.
16. Sonis J, Gibson J, Jong J, et al. Probable posttraumatic stress disorder and disability in Cambodia: associations with perceived justice desire for revenge and attitudes towards the Khmer Rouge trials. JAMA. 2009; 302(5): 527-536.
17. Friedman M. The truth and reconciliation commission in South Africa as an attempt to heal a traumatized society. In: Shalev AY, Yehuda R, McFarlane AC, eds. International Handbook of Human Response to Trauma. New York, NY: Plenum Publishers; 2000: 399-411.
18. Orth U, Maercker A. Do trial perpetrators retraumatize crime victims? J Interpers Violence. 2004; 19(2): 212-227.

This year eerily similar stories of tragedy have filled the newspapers. A man loses significant amounts of money because of the current financial crisis and shoots himself. A father is unable to support his family, so he shoots them and then kills himself. Some of these individuals have previous psychological issues but many do not. There is a positive correlation between economic recession and suicide rates. Decreased funding for social services may make it difficult for those who have lost jobs and insurance coverage to receive help if they need it. The National Suicide Prevention Lifeline phone calls increased to 50,000 a month in 2008, about 35% higher than the previous year. Suicide not only affects individuals directly involved in the act, but also their families and the community at large. In the United States, one person kills themselves every 15.8 minutes and it is estimated that at least six individuals are intimately affected by each suicide [1].

The 2008 Supreme Court declaration affirming the right of individuals to keep and bear arms (District of Columbia v. Heller) only aggravated the situation by encouraging higher firearm ownership rates [2]. 55.4% of all firearm-related deaths in the United States are due to suicide and there is a direct correlation between probability of suicide and firearm accessibility. In the first year after the purchase of a handgun, suicide is the leading cause of death among handgun purchasers [3]. Gun owners in America think that if they confront armed intruders with the weapon it will scare them away. Households where a firearm is kept are five times more likely to experience a suicide than those that are gun-free [4]. A gun kept at home is 11 times more likely to be used to commit or attempt a suicide than to be used in self-defence [5].

In extensive studies conducted by Killias [6], significant correlations were found between gun ownership and gun-related suicide and homicide rates. He found no indication that suicidal individuals will turn to knives or other lethal means when guns are not present. Widespread gun ownership was not found to reduce the likelihood of fatal events committed with other means. It is uncertain if the higher suicide rates of gun owning countries are due to overall increased violence or to the increased risk of fatality with a firearm (WHO statistics tally deaths only, not attempts).

In Britain, the simple change from coal gas to natural gas in the 1970s was extremely successful in reducing the suicide rate. Coal gas in a closed space (“Sticking one’s head in the oven”) was deadly in minutes. People did not use other methods to take their lives and the suicide rate dropped dramatically. They could not act as impulsively as before. If the method took more time, the violent impulse dissipated. It has also been documented that of all the people from 1937 to 1971 who planned to jump off San Francisco’s Golden Gate Bridge but were thwarted, only 6 percent went on to kill themselves [8].

More than 90% of suicide attempts using guns are successful, compared to the success rates of jumping from high places (34%) or drug overdose (2%) [7]. Of the 32,637 suicides in the United States in the year 2005, 17,002 of these deaths involved firearms – over 52% [2]. Many of those whose suicide attempt is unsuccessful are later grateful for a second chance at life. Unfortunately, with firearms, the success rate is too high for most to have a second chance. Ironically, those that kill themselves with firearms have a lower history of long term psychological issues – depression, bipolar disorder, schizophrenia, previous suicide attempts- than those who die by less deadly methods. There is a good chance that these folks would go on to live productive, happy lives if the suicide attempt failed. But with guns, the attempt is usually fatal.

Some of the solutions or suggestions to reduce the rate of suicides by firearm (and hence the overall suicide rate) are simple and relatively easy to implement. The ideal of course would be to remove guns from households; the next best thing would be to make sure guns are locked up securely and stored away from ammunition. Shooting oneself is an impulsive act and putting time between the person and the act can make the difference between life and death. Another option is of course, gun regulation including extensive background checks and a waiting period when purchasing a firearm. Supporters of gun rights are not convinced by the research that has been done and by the evidence that has been found. But how much time will we allow ourselves to wait and how many lives will be lost before we take any steps to curb gun ownership rates?

Shaheen Lakhan is currently Executive Director of the Global Neuroscience Initiative Foundation based in Los Angeles, California. Elissa Hamlat is a GNIF Research
Assistant.
slakhan(at)gnif.org

References

1. McIntosh JL. USA suicide 2006: Official final data. Washington, DC: American Association of Suicidology. 2009. Available at http://www.suicidology.org

2. Kung HC, Hoyert DL, Xu J, Murphy SL. Deaths: Final Data for 2005. CDC National Vital Statistics Reports. 2008; 56(10). Available at http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.pdf

3. Wintemute GJ, Parham CA, et al. Mortality among recent purchasers of handguns. The New England Journal of Medicine, 1999; 341:1583-1589.

4. Cummings P, Koepsell TD, Grossman DC, Savarino J, Thompson RS. The association between the purchase of a handgun and homicide and suicide. American Journal of Public Health, 1997; 87(6):975.

5. Kellermann AL, Somes G, Rivara FP, Lee RK, Banton JG. Injuries and deaths due to firearms in the home. The Journal of Trauma. 1998; 45(2)263-267.

6. Killias M. “Gun ownership, suicide and homicide: an international perspective.” In, Understanding Crime and Experiences of Crime and Crime Control, del Frate, A., Zvekic, U. and van Dijk, J.J.M. (Eds.). UNICRI Publication No. 49. Rome: UNICRI. 1993. Available at http://www.unicri.it/wwk/publications/books/series/understanding/19_GUN_OWNERSHIP.pdf

7. Miller M, Azrael D, Hemenway D. The epidemiology of case fatality rates for suicide in the northeast. Annals of Emergency Medicine. 2004; 43(6):723-730.

8. Anderson S. (2007, July 6) The Urge to End It All. The New York Times. Available at http://www.nytimes.com/2008/07/06/magazine/06suicide-t.html

Andrey Ostrovsky tells us how lessons learned from healthcare on an international level can be applied to local healthcare systems.  

International Health has gained significant momentum in the past few years, making it one of the trendiest avenues of medical practice (1). As the machine of global medicine quickly accelerates toward improving health conditions abroad, domestic healthcare issues must not be allowed to fade from view. Overcoming international and domestic healthcare obstacles may pose different challenges, but the approaches to overcoming these challenges are not mutually exclusive. Several lessons from attempts to administer health systems in developing countries are applicable to all health systems. It is time to apply the lessons learned abroad to problems faced at home. The following overview of lessons from developing countries is meant to serve two functions: 1: to remind doctors practicing abroad that they have unique expertise which is much needed at home, and 2: to encourage health system administrators to think outside the box – and the borders – when addressing local healthcare issues.

Donor Fund Allocation 

The first lesson pertains to one of the most salient issues in health system strengthening, which is the proper allocation of funding. This issue is not a matter of how much money is being pledged to aid developing countries, but rather where the money is going. Earmarked funding for AIDS alone or TB alone or Malaria alone creates several parallel programs that stifle health system integration. For example, in Uganda, international agencies’ funding of HIV and AIDS programs exceeds the entire Ugandan government’s health budget (2). Consequently, these programs paralyze the local governments by congesting too few avenues with too much money. Instead, funds should traverse through an integrated network of thoroughfares which would lead to general health system strengthening. The lesson here is to efficiently address the major diseases simultaneously by bolstering the ministry of health as a whole and using it as a common foundation upon which individual disease interventions can be constructed.

 This lesson is sadly ignored in developed countries like the United States. While several states have made valiant efforts to create universal access to healthcare, the majority are lagging. Much of the contention, as usual, comes down to funding. Politicians argue that it is too expensive to fund programs that provide universal access, so they concede to fund piecemeal interventions that only address solitary problems even though universal access can actually be less expensive. For example, in the state of Maryland, a beautifully crafted proposal for universal healthcare access is projected to cost $3.1 billion per year, whereas the current annual budget for healthcare exceeds $22 billion (3,4). Unfortunately, political and financial pressures will likely defeat the fiscally sound Maryland proposal and perpetuate a disjointed health system.

Role of Economics in Health Outcomes

Whether seeking to reform the health system of a small state or an entire country, the issue of money inevitably accompanies the issue of medicine. Another key lesson from developing countries is that socioeconomic determinants are linked to health outcomes (5). To elucidate that link, the World Health Organization (WHO) used data from developing countries to create a conceptual framework for understanding the complex relationship between health and its various determinants. The framework encompasses the direct and indirect effects of the national economy, household economies and health-related sectors on population-level and individual health (6). The WHO builds on this framework and codifies a key lesson by highlighting that the health of poor populations can be improved through economic interventions.

 Some developed countries lose sight of the reciprocal relationship between the economy and health outcomes. In a time when financial stability of even the wealthiest nations is in jeopardy, policy makers are reluctant to commit significant funds toward healthcare. What must be realized from lessons from abroad is that stabilization of the economy is contingent upon a stable healthcare system. For example, if the current fiscal constraints cause a flood of people to lose their jobs, they would ultimately be unable to pay for their medical care. Subsequently, large medical bills would go unpaid, hospitals would accrue debt, and providers would not be paid for their services. This scenario could quickly snowball into the healthcare system equivalent of the U.S. banking crisis. By saving old jobs and/or creating new jobs that provide a means to pay for healthcare, the economy can be used to bolster population health. Healthier people would make more productive workers and in turn boast the economy. Fortunately, the Obama administration quickly realized this association by making healthcare a top priority in times of extreme financial turmoil. This and other developed nations should not think of investment in healthcare and the economy as two separate, high-priced bank notes, but rather as different sides of the same frugal coin.

Vertical and Horizontal Health System Integration 

 Experiences in developing countries teach that providing adequate care in resource poor settings requires more than just economic stimulation; it also requires vertical and horizontal integration of the health system. In a poorly integrated system, top-down administration, such as country-wide ministry of health mandates, has limitations because the needs and resources of each locality may be different. To address this problem, a 2005 WHO consortium of government officials and NGOs from developing countries recommended that local actors need a place at the national policy table to give appropriate perspective, offer education, and provide access to care (7). This recommendation affirms that health system information and interventions must be vertically integrated from the bottom-up as well as from the top-down to properly address all parties’ healthcare needs. Additionally, experts in health system administration in low-income countries suggest that collaboration between parties at the same health system level would promote better provision of services (8). Thus, horizontal integration through side-to-side communication between various health sectors can augment vertical integration by avoiding unnecessary bureaucratic obstacles or duplication of services.

 The tenets of vertical and horizontal integration can similarly be applied to developed countries to improve access to care. In the state of Maryland, a single county did just that. Healthy Howard is an effort spear-headed by the former Baltimore City health commissioner, Peter Bielenson, that created universal access to healthcare for all residents in Howard County (9). The initiative utilizes vertical integration by having county officials advocate for local healthcare needs by soliciting state funding. Additionally, various parallel services offered through the health commission, private industry, tertiary hospitals, and health interest groups are horizontally integrated into a net that covers almost every constituent’s health needs. Although Healthy Howard is an example of successful health system integration leading to universal access to care in a developed nation, it is the exception rather than the rule.

Messaging

The success of Healthy Howard would not have been possible without the right messaging. Messaging comes in two flavors. Positive messaging, also known as framing, is taking true messages and making them known to the public through accurate education.  Negative messaging, or spin, is conveying messages in a misleading way that obscures the true content of the message. In developing countries, where there is so much misunderstanding about health issues, health interventions are futile without the right messaging.

 The importance of messaging in developing countries is highlighted in an HIV prevention study of over 600 men in Ghana. The data show that perception of condom efficacy strongly influences actual condom use (10). In other words, health information must be properly framed in order to influence behavior. Fortunately, positive messaging has been quite effective. In Brazil, an advertisement campaign focusing on safe sex was developed in response to statements by some religious leaders questioning the efficacy of condoms in preventing HIV infection. The campaign effectively educated the public and influenced condom use in the country (11). Unfortunately, messaging is effective even if it is negative. For example, the Bush administration’s President’s Emergency Plan for AIDS Relief (PEPFAR) mandate overemphasized abstinence and faithfulness to the exclusion of condom prevention strategies. The mandate’s misguided focus resulted in “major funds going to religious groups with little or no experience in either AIDS programs or Africa more broadly” (12). Consequently, the spin from these groups regarding HIV prevention is largely skewed. Studies show that abstinence-only programs run by such groups have “high rates of failure in terms of both infection and other adverse outcomes such as unintended pregnancy” (13). Messaging campaigns in developing countries provide the lesson that public perception is a determinant of public health.

 Messaging falls under the purview of Public Relations (PR), and in developed countries this is a booming industry. However, PR has not been fully utilized by the medical establishment to appropriately frame the major healthcare issues. Medicine has spread beyond the walls of hospitals into the arenas of law, business, and even entertainment; it’s time for medicine to start doing PR. In a society saturated with spin on healthcare, medicine must recruit PR experts to influence policy makers and the public to embrace productive changes to the current health system.

Conclusion

Using these lessons, health systems in developed countries can be bolstered by refining fund allocation, incorporating healthcare with the economy, integrating health sectors, and employing effective messaging. In an era where communication with the opposite end of the world is no longer limited by mileage but rather by band-width, sharing ideas between developing and developed countries is easier than ever. With globalization at a peak, physicians with global health experience are perfectly suited to make significant contributions both at home and abroad. The medical establishment should encourage more physicians to engage in international health in order to continue generating transposable lessons in health system strengthening.

Andrey Ostrovsky is a third year medical student at the Boston University School of Medicine.
andrey@bu.edu

References

 (1) Ostrovsky A. Global health is “the new pink”. Lancet Student 2008. Available at http://www.thelancetstudent.com/2008/11/19/global-health-is-%e2%80%9cthe-new-pink%e2%80%9d/

 (2) England R. The dangers of disease specific programmes in developing countries. 2007. BMJ, 335 (7619):565. 

(3) Maryland Citizens’ Health Initiative. “Health care for All” Plan Proposal. 2008. Page 1. Available at <http://www.healthcareforall.com/parameters/healthcareforall/uploads/dl/2008_HCFA_Plan/MD_HCFA_Plan_2008-11-12.pdf>

(4) Wilson DE. State Health Care Expenditures. Maryland Health Care Commission. 2004. Page 9. Available at <http://mhcc.maryland.gov/health_care_expenditures/shea02/shea2002.pdf>

 (5) Mosely WH & Chen LC. An analytical framework for the study of child survival in developing countries. Population and Developmental Review. 1984, 10: supp25-45.

 (6) Woodward D; Drager N; Beaglehole R; & Lipson D. Globalization and health: a framework for analysis and action. 2001. Bull World Health Organ, 79(9). 

 (7) Travis P & Bennett S. The “Montreaux Challenge”: Making health systems work: Background paper. WHO. 2005. Available at  http://www.who.int/management/background_1.pdf

 (8) Bennett S, Hanson K, Kadama P, & Montagu D. Working with the non-state sector to achieve public health goals: Background Paper. WHO. 2006. Available at  http://www.who.int/management/background.pdf

 (9) Howard County, MD Government. Healthy Howard Access Plan. Healthy Howard. Available at http://www.howardcountymd.gov/Health/HealthMain/Health_HHAccessPlan.htm.

 (10) Adhi WK & Alexander CS. Determinants of condom use to prevent HIV infection among youth in Ghana. J Adol Health. 1999;24:63-72.

 (11) Okie S. Fighting HIV — Lessons from Brazil. NEJM. 2006:354(19);1977-1981

(12) Dietrich J. The Politics of PEPFAR: The President’s Emergency Plan for AIDS Relief. Ethics and Int Affairs. 2007;21(3):277-292.

(13) Center for Health and Gender Equity, Debunking the Myths in the U.S. Global AIDS Strategy: An Evidence-Based Analysis, March 2004, p. 8. Available at http://www.comminit.com/en/node/181474/36.

James Matheson writes on how healthcare in Iraq has been shaped by past and current politics. 

This article examines political factors before and after the 2003 US-led occupation, contributing to Iraq’s failing healthcare system, documented by Medact’s reports. (1)

Saddam Hussein came to power in 1979 with early healthcare improvements evidenced by decreasing child mortality, but his repression of disfavoured populations by withholding medical services (2) and a combination of his belligerent actions and their political exploitation internationally reversed this trend. The West’s support of an eight-year war with Iran evaporated when Saddam invaded Kuwait in 1991 threatening oil price stability and, after military defeat by a US-led coalition, Iraq came under UN sanctions.

Some claimed 1.5M people died from sanctions. (3) Certainly mortality more than doubled in under fives in the south. (4) In the autonomous Kurdish region, protected by allied intervention, mortality did not increase allowing suggestions that Saddam’s influence, rather than sanctions, was to blame. When the ‘Oil for Food’ programme began, however, health improved. (4) (more…)

Amelia Cutts writes on conflict and child health, with a particular focus on Haiti and Sudan. 

The concept of power and politics affecting the health of a nation’s population is not a new one. Political instability is a common cause of poor health in a nation, leaving many civilians without access to clean water, adequate food supplies and medication. Young children are affected more than any other group in the population as they are more susceptible to malnutrition and are more likely to contract diseases such as cholera due to lower levels of immunity. (1)

During the American civil war in the 1860s, the health of the population suffered immensely. The primary reason being that there were few, if any, men left to work on the farms that sustained the towns and villages with food, as they were all at war. Estimates suggest that between 320,000 and 650,000 men died during this conflict, but many of these were from disease rather than as a result of direct conflict. Some sources say that this was as much as 3% of the population, having a profound affect on the lives of civilians at the time. (2) (more…)

Keir Philip writes on the ’Convoy to Cape Town’, a major event raising awareness of maternal health in South Africa.

On the dusty floor of Cato Manor township near Durban, the air pulsating with the collaborative efforts of South African and British musicians from the White Ribbon Alliance ‘Convoy To Cape Town’, I sat surrounded by 15 children from the local orphanage and asked them ‘Why can pregnancy and giving birth be dangerous?’

I already knew the issues; I’d read them in a book. 80% of maternal deaths result from direct obstetric complications including haemorrhage (bleeding), infection, unsafe abortion, hypertensive disorders and obstructed labour. The children knew the issues; their mothers had died because of them. And I already knew the statistics; I had read them in a report. One woman dies every minute of everyday from pregnancy related causes. The children knew the life those statistics described. In one of those minutes, on one of those days, that dying woman was their mother. As soon as my friend MC Black Moss had translated to Zulu, pens hit paper. The responses became images, which in turn became banners. By circumventing language barriers through the universal language of art, each child’s voice was given a chance to be heard, ‘People can’t afford to travel to hospital’, ‘men are beating women’, ‘some women don’t have a break from work around birth’. And, unsurprisingly, ‘the virus is killing mothers’, as HIV/AIDS is the leading cause of maternal mortality in South Africa. Through raising awareness of the situation for women, which was the intention of the convoy, politicians can be made accountable and forced to make the changes that women are entitled to. This should be seen as a fundamental step in tackling these issues in an effective and sustainable manner. (more…)

Jonny Currie writes on the need for change in the world order and the importance of students in making this happen. 

Whoever said student apathy was rife? Look around you and I feel confident that you will find otherwise. For a phrase that has been commonly attached to students recently, (1) we are failing to acknowledge the rising tide of enthusiasm amongst the youth of today on a diverse range of issues. Students facing their universities and their spurious environmental policies; (2) students tackling an unjust availability of medicines in resource-poor countries; (3) I am heartened, not cynical, that the youth of today will be the change of the tomorrow. (more…)

Justin Healy writes on the inextricable links between medicine and politics. 

Taken in photographic isolation, the art of medicine, whether the inoculation of a child or the replacement of a heart valve, would appear to be the most apolitical of all acts.  In the context of a medical consultation there should be no consideration given to any agenda other than the benefit of the patient.  Matters of colour, faith, political opinions and even criminality are not supposed to interfere with the doctor’s ultimate responsibility to the sick person before them.  This is not merely blind idealism; from Hippocrates to the GMC doctors have been exhorted to look first to the well-being of their patients. (1, 2)  For a doctor to place a political agenda above the health of their patient would be crass, insulting and positively dangerous.

And yet, the arts of medicine and politics have grown to be inextricably linked.  A rickety scaffold of political machinations that supports the platonic ideal of the doctor-patient alliance.  Though politics may have no place in a medical consultation; it most certainly determines who built the consulting room, how the doctor is paid and what treatments the patient may get.  It is a blissful ignorance that declares medicine independent of the dark arts of politics. (more…)